[NAME OF PRACTICE]



Employee: ____________________________________________________________________________________

Last Name First Name Middle Name

Employee SSN # or Work Comp Claim #: __________________________________________________________

Employer: ____________________________________________________________________________________

Address: _____________________________________________________________________________________

Number & Street City State Zip[pic]

-----------------------

WORK RELATED INJURY

Site of Injury:__________________________________________

WORK COMP INSURANCE INFORMATION: (ex: Sedwig, Accident Fund)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name & Address where to send a claim:

________________________________________________________________________________________________________________________________________________________________________________________________________

Special Instructions:

________________________________________________________________________________________________________________________________________________________________________________________________________

We agree to be financially responsible for any medical treatment/services provided to the employee named above.

Authorized Signature:_______________________________

Print Name:_______________________________________

Phone:____________________________________________

Fax:______________________________________________Date:_____________________________________________

CATEGORY OF SCREENING

DOT Non-DOT

TYPE OF SCREENING

Hair

Breath Alcohol

Urine

6-panel

10-panel

REASON FOR SCREENING

Pre-Employment

Random

Reasonable Cause

Post-Accident

Follow-Up

Other_______________________

PHYSICAL EXAM

Pre-Employment

DOT Initial

DOT Recertification

OTHER SERVICES

Audiogram

Chest X-ray

EKG

Hepatitis B

Injection #1

Injection #2

Injection #3

TB Skin Test

Tetanus

Pulmonary Function Test

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